General Practice Reimagined

General practice seems to be in a bit of a pickle. Surely it cannot get any worse. The reality is however that it is likely that GP numbers will continue to decline with few new physicians assistants, specialist nurses or any other GP substitutes appearing on the horizon. The funding gap described in emerging STPs seems likely to eclipse any possible benefit from increased NHS funding to general practice promised in GP Forward View. 

Most GPs will continue to resist changing the model of their practices from that of a corner shop, tending to join federations out of fear with a vague notion that there must be safety in numbers. Federations and super-partnerships are starting to take shape but for many they are becoming a Frankenstein’s monster which could potentially consume the very practices that set them up, both financially or existentially. It really could get worse.

So what hope for the future? When will we start seeing the sort of practice we would all want to work in, would not want to retire early from and would find willing recruits to come and join us? Is it too late to start imagining this sort of practice ever existing?

The ideal

Imagine a practice which allowed GPs to focus on caring for patients with colleagues expertly handling the management and admin of the business. GPs would receive an income that was reasonable and uniform according to experience, expertise and workload. They would work in a clinical team where patients are seen by the person best suited to their needs.”

Patients would have excellent access to primary care services, personalised care being provided in every patient contact and continuity of care where it matters. Care would often be provided by non GP based services with practices increasingly becoming care ‘navigators’ and not simply NHS gatekeepers.

Quality improvement would be at the heart of the practice and not something done to the practice episodically by CQC. There would be dedicated time to meet with colleagues where honest conversations would take place about how practitioner’s activity and performance varies or is at variance with expert guidance. There would be coffee breaks.

A clinical governance team would be crunching data and producing useful reports which would not only be included as QIA in our annual appraisal but might actually result in quality improvement in patient care. Educational sessions would be mainly small group based, local, in working time and be related to identified learning needs.

Perhaps most importantly patients would receive a more comprehensive and more accessible NHS. The workforce would be recruited and trained to manage the changing pattern of healthcare need in the community. GP and community teams would be indistinguishable with health and social care workers being co-located and working collaboratively. GP teams would become advocates for their community and not just reacting to the needs of patients who have successfully battled their way through the appointment system. Patients would become partners in the development of their local NHS.

The transition

How could this come about? It would first and foremost require GPs to let go of the control of their small businesses forming larger and leaner provider organisations. It would also require assessment of patient needs, promptly and expertly, capitalising on the specialist skill of GPs in risk assessment and management; problems often managed on-line, on the phone and by non GPs but with continuity of care where it matters. Longer appointments would need to be available for GPs to deal with complex problems with recognition that GPs do not have a monopoly on personalised care, the management of complexity or holistic practice.

There are some practices where this vision is becoming a reality. Des Smith describes his experience of working in a 35k patient practice in Glasgow where all staff have a stake in the partnership which runs as a local not-for-profit social enterprise. (1) The Primary Care Home model developed by NAPC is being piloted across 15 sites in England, soon to rise to over 100 sites. (2) This community based model focuses on populations of 20-50k where team members feel part of the organisation and the ‘fund-holding’ ethos allows creativity and enterprise in the use of limited NHS resources for better patient outcomes. Team members in both models feel part of the venture and have the potential to influence the service and feel they are making a difference.

“What is clear is that more of the same is not going to be the way forward. The GP Forward View promises additional resources but linked with reforms. Perhaps general practice needs to be reimagined and not reformed allowing us to recapture the spirit and essence of our specialty which is truly fit for a 21st century NHS. ”  


Dr Ashley Liston FRCGP

RCGP Regional Ambassador

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